Jennifer Krupa Shah

The federal government recently passed legislation that will significantly reduce Medicaid spending through work requirements. Burns disproportionately affect the Medicaid population and are one of the most costly injuries with some admissions incurring multimillion dollar hospital stays. All admissions with a primary burn diagnosis were extracted from the National Inpatient Sample, 2017-2022. Cost-to-charge ratios were applied and adjusted for inflation to 2025 US dollars. Facilities were stratified by burn center and safety-net status. Reductions in Medicaid enrollment were modeled using US Congressional Budget Office estimates. Projections of burn care and burn center losses over a 6-year period with 95% CIs were derived from Monte Carlo simulations using bootstrap resampling distributions. Of 178 545 weighted burn encounters, 39 575 under 18 years old were excluded as children will not be affected by the new law. The frequency of burn encounters covered by Medicaid has increased by 7.0% over the past 6 years. The total annual cost of burn care is estimated at $3 190 265 497, 28.4% of which is costs to Medicaid. Burn center costs to Medicaid increased by 18.9% over the 6 studied years. Assuming the current trajectory of inpatient admissions, the overall reduction in Medicaid payments from burn care is estimated at $525 645 056-$717 992 704. 33.1% of Medicaid encounters were treated at safety-net hospitals, which will incur a 2.70% reduction in burn center funding. Non-safety-net hospitals will incur a 2.39% reduction. Revenue-generating strategies and cost containment may be insufficient for financial solvency in some burn centers.

Discharge against medical advice (AMA) leads to worse outcomes in patients with burn injuries, including higher readmission rates, wound complications, and elevated costs, although protective and risk factors remain incompletely characterized. Burn encounters were identified in 2 national databases, the Nationwide Inpatient Sample (NIS), 2016-2021, and the Burn Care Quality Platform (BCQP), 2016-2022. Encounters were stratified by AMA discharge. The primary outcomes were the overall incidence of AMA discharge and the effects of inpatient psychosocial or behavioral interventions and burn center status on AMA discharge, evaluated with 1:1 nearest-neighbor propensity-score matching of AMA and non-AMA encounters on demographics, burn characteristics, and established risk factors for AMA discharge, without replacement and with a maximum caliper distance of 0.1. In the NIS and BCQP, 5950 (2.8%) of 214 390 and 2923 (1.4%) of 205 993 burn encounters, respectively, were discharged AMA. Significant predictors of AMA discharge included male sex, Medicaid or self-pay insurance status, smaller burn size, and a more recent admission year (P < .01). The incidence of AMA discharge increased over the study period in both the NIS (incidence rate ratio [IRR] 1.2; 95% CI, 1.1-1.2; P < .01) and the BCQP (IRR 1.2; 95% CI, 1.2-1.2; P < .01). Within a propensity-score matched model, burn center care was associated with a 1.2% decrease in AMA discharge (average treatment effect, −0.01; 95% CI, −0.02 to −0.00; P = .01); psychosocial or behavioral interventions did not impact the likelihood of AMA discharge (P = .85). Existing interventions to mitigate AMA discharge are insufficient to significantly alter these patterns. Treatment at a burn center may result in a lower likelihood of AMA discharge in patients with burn injuries.

Background: Lymphedema is a chronic disease characterized by swelling, inflammation, adipose deposition, and fibrosis. In the United States, lymphedema occurs most frequently as a sequela of oncologic lymphadenectomy. Axillary lymph node dissection (ALND) for breast cancer has been associated with a 5%–40% incidence of upper limb lymphedema. In immediate lymphatic reconstruction (ILR), surgeons perform lymphovenous anastomosis (LVA) with ALND to prevent the development of future lymphedema. Although early evidence supports a protective effect of ILR, there have been few large-scale studies on the topic. We leveraged a large claims database to better characterize the outcomes of ILR and national trends related to its adoption. Methods: Adult female patients with breast cancer who underwent axillary lymph node dissection (ALND) between 2007 and 2022 were identified within the Merative MarketScan Research Databases and stratified according to whether they underwent ILR. Adjusted odds of undergoing ILR, both overall and regionally, and of experiencing postmastectomy lymphedema syndrome (PMLS) were calculated. Results: Of all patients undergoing mastectomy and ALND, 1.3% received ILR. ILR was associated with decreased odds of developing PMLS (OR, 0.81; P = 0.02). The frequency of ILR procedures increased in all regions between 2017 and 2022, most dramatically in the Midwest and East US. More recent surgery year, younger age, complete mastectomy, and delayed ALND elevated the odds of undergoing ILR ( P ≤ 0.01). Conclusions: The popularity of ILR has grown rapidly since 2017, with significant regional variability. Patients with breast cancer who undergo ILR at the time of ALND are significantly less likely to develop lymphedema.

Neuroma complicates lower extremity (LE) amputations causing significant morbidity. This study examines the relationship between access to plastic surgery and the likelihood of receiving a neuroma-preventing nerve procedure with LE amputation in the United States. Using the National Inpatient Sample, 2016 to 2021, ICD-10 codes identified encounters undergoing above- or below-knee LE amputation with or without concurrent nerve procedures (targeted muscle reinnervation and regenerative peripheral nerve interface). Plastic surgery volume was determined using ICD-10-PCS codes. Outcomes included population-adjusted LE amputation incidence, odds of concurrent nerve procedures, and their incidence relative to facility plastic surgery volume. Statistical analysis included univariate analysis and multivariate Poisson and logistic regression models. A total of 245,170 weighted encounters underwent LE amputation, of which only 1,525 (0.6%) included concurrent nerve procedures. Population-adjusted LE amputation incidence remained stable throughout the study period (p = 0.159). Higher LE amputation incidence was associated with higher comorbidity burden and Black and Native American race (p ≤ 0.036). Odds of nerve procedures increased with more recent surgery year, younger age, higher income, and Black race (p ≤ 0.044). Nerve procedure incidence at facilities in the highest quartile of plastic surgery volume was significantly higher than that of facilities in the lowest quartile (incidence rate ratio: 21.949; 95% confidence interval: 16.493–29.211; p < 0.001). Amidst stable population LE amputation incidence, Black and Native American race increased LE amputation incidence. Higher income and Black race elevated odds of concurrent nerve procedures. Increasing facility plastic surgery volume was associated with increased concurrent nerve procedure incidence in LE amputation.

Tracheostomy is indicated in critically ill patients when prolonged mechanical ventilation is anticipated. We leveraged national data to evaluate tracheostomy timing in burn patients, hypothesizing that early tracheostomy would be associated with reduced length of stay (LOS) and ventilator-associated pneumonia (VAP). Surviving burn encounters undergoing tracheostomy in 3 national databases—Nationwide Inpatient Sample (NIS), 2016-2021, National Trauma Data Bank (NTDB), 2007-2014, and Burn Care Quality Platform (BCQP), 2015-2022—were stratified by tracheostomy timing relative to admission: early: ≤10 days versus late: >10 days. Early tracheostomy encounters were propensity-score-matched with late tracheostomy encounters on age, sex, and total body surface area (TBSA) of burns to evaluate the impact of tracheostomy timing on LOS, ICU LOS, ventilator days, VAP, discharge to inpatient rehabilitation, and discharge to long-term acute care (LTAC). In total, 9173 burn encounters underwent tracheostomy (6255 in NIS, 1332 in NTDB, and 1586 in BCQP), of which 51.1% were early. Within matched cohorts, early tracheostomy was associated with shorter LOS, reported as average treatment effect, in days (95% confidence interval): NIS: −22.9 (−32.8 to −13.1), P < .01; NTDB: −12.7 (−18.7 to −6.8), P < .01; BCQP: −7.0 (−12.5 to −1.5), P < .01. Early tracheostomy was associated with shorter ICU LOS and fewer ventilator days in NTDB and BCQP (P < .04). Early tracheostomy was not associated with discharge to inpatient rehabilitation or VAP. Early tracheostomy decreased discharge to LTAC in NTDB and BCQP (P ≤ .02). Our multi-database analysis supports early tracheostomy in critically injured burn patients requiring prolonged mechanical ventilation.

Introduction: Gender-affirming surgery (GAS) is a complex process that often requires multiple surgical operations and carries a complication risk that could be exacerbated by connective tissue disorders (CTDs). This study aims to investigate the association between CTD diagnosis and GAS outcomes. Methods: Using the Merative MarketScan Research Databases, patients with gender dysphoria diagnoses who underwent GAS between 2007 and 2022 were identified. Among these, patients with diagnosed CTDs were identified. Demographics, comorbidities, and postoperative complications were recorded. Chi-squared, Shapiro-Wilk, Wilcoxon-Mann-Whitney, and multivariate logistic regression testing was used for statistical analysis. Results: Of 7575 patients meeting criteria (mean age 29 ±10 years), 300 (4%) had CTD diagnoses. One or more postoperative complications were recorded in 9.8% of patients, without statistically significant difference between CTD and non-CTD patients. Additional simultaneous GAS procedures [odds ratio (OR) 2.02; P < 0.01], Elixhauser index scores of 3+ (OR 1.36; P = 0.010), and age >45 years (OR 1.47; P = 0.02) increased odds of experiencing complications following the index GAS procedure, while CTD diagnoses (P = 0.52) did not affect odds of experiencing complications. However, CTD diagnoses did elevate odds of readmission (OR 1.47; P = 0.046), as did multiple simultaneous GAS procedures (OR 2.66), Elixhauser index scores of 3+ (OR 3.72), and smoking (OR 2.18) (P < 0.01). Conclusions: These findings suggest CTDs may impact some gender-affirming surgical outcomes, and careful preoperative evaluation and management of comorbidities is necessary to reduce the risk of complications and readmission in this population. Surgeons should continue to exercise caution when performing elective surgery on patients taking immunomodulatory medications.

Professional health care organizations including the American Society of Plastic Surgeons (ASPS) historically provide guidance to medical providers in the wake of major medical news and events. Consider, for example, the ASPS guidance published in response to the December 17, 2020 Food and Drug Administration (FDA) briefing document of the Vaccines and Related Biological Products Advisory Committee for the Moderna COVID-19 (coronavirus disease 2019) Vaccine.[1] This information provides a framework for physicians to guide patient-physician conversations in formalized health care settings. However, it provides little insight into tangible patient concerns during the contemplation stage of decision-making prior to formalized patient consultations. We suggest utilizing Google Trends (GT) as a real-time tool to aid in identifying patient concerns. There have been several previously published case reports commenting on the immunogenicity of hyaluronic fillers as well as COVID-19 vaccine hypersensitivity and dermal manifestations.[2] [3] [4] [5] In theory, statements from professional organizations have a broader audience base than research articles from independent bodies including research institutions and universities. Few tools are available to both analyze how the public perception changes and capture significant concerns in the wake of these statements. In this virtual era where health-related information is readily accessible to patients via Internet searches, patients often form biases and premature decisions regarding treatment options prior to ever setting foot—or meeting virtually—in a provider's office.[6] [7] Additionally, there is an ever-growing body of literature supporting the use of social media and its utility in communicating with patients, particularly within the field of plastic and reconstructive surgery.[8] [9] [10] In order for physicians to address patient concerns on their Web-based platforms in the absence of in-person patient consultations, we advocate for the use of free analytical tools, particularly GT, to predict and mitigate patient concerns. We used a GT analysis to examine whether public interest in and concern over dermal fillers and related injectable products, namely botulinum toxin, increased in the wake of FDA adverse event reports, specifically the aforementioned December 2020 FDA Briefing. In our analysis, the following search terms ([Table 1]) were queried on GT (Google LLC., Mountain View, CA). These search terms were grouped by the following categories: general terms, adverse reaction terms, safety consideration terms, procedural terminology, brand names of botulinum toxin, and brand names of dermal fillers. These search terms were chosen to capture the various aspects of patient concerns regarding these products, their uses, and safety with respect to the COVID-19 vaccine. The search terms were gathered from November 1, 2019 to November 1, 2021. These dates provided a year's worth of data before and after the inflection point—November 1, 2020—which was chosen to capture the media coverage leading up to the official FDA statement released in December 2020. GT normalizes the volume of the search terms to compare them against one another. Thus, the data extracted is assigned a value from 0 to 100 to represent the relative search volume for each term. Once the data had been extracted from the GT platform for each search term, a bivariate regression analysis of panel data was utilized to explore whether or not the search term volumes were significantly increased after the chosen inflection point of November 1, 2020, as compared with the search volume prior to the inflection point. The data inputs were grouped by search volume for each term up to the inflection point of November 1, 2020, and search volumes for each term following the inflection point. Significant increases or decreases were statistically determined with a p-value of < 0.05 at a 95% confidence interval. [Table 2] demonstrates that general terms (p < 0.001), safety consideration terms (p = 0.034), procedural terminology (p < 0.001), brand names for botulinum toxin (p < 0.001), and brand names for dermal fillers (p = 0.049) had significantly different relative search volume before versus after the chosen inflection point of November 1, 2020. Our GT analysis demonstrated a significant increase in search terms, and therefore public interest, related to injectable products, the COVID-19 vaccine, and their adverse effects following the December 2020 FDA Briefing. GT analysis allows providers to accurately query public interest in, and concern over, medical procedures in the absence of face-to-face, individual patient meetings. Using free, publicly available analytical tools allows physicians the ability to tailor patient education on social media or other Web-based platforms to anticipate and mitigate patient concerns. M.A.R. and K.T. were involved in conception, writing, and editing. J.K.S. was involved in data collection, analysis, and writing. R.N. was involved in conception and editing. Received: 27 January 2022 Accepted: 30 June 2022 Article published online: 28 March 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA